ABOUT
ADVANCE
DIRECTIVES
You have a right to decide what treatments
you want or don’t want, and who makes these
decisions should you be unable to make them
for yourself. This booklet will tell you how.
Address any questions or concerns about
Advance Directives to Pastoral Services at 3539463.
ABOUT ADVANCE DIRECTIVES
It is important for you to know that Indiana law protects your
what medical treatments you want or don’t want. right to
decide
about your health care wishes and whom you appointed to
carry them out.
You can tell your doctor or loved ones these decisions, so
that if you become too sick to tell them they'll know what
you want them to do.
No. You have the right to make an advance directive if you
want to, and no one can stop you from doing so. But no
one can force you to make an advance directive if you don't
want to, and no one can discriminate against you if you
don't sign one.
You can choose someone you trust to make these
decisions for you if you become unable to make them for
yourself.
You can write these decisions down on a paper called an
advance directive.
For more information, keep on reading!
What happens if I become unable to make my own
medical decisions?
Unless you do something, your health care decisions will be
made by someone else if you become unable to consent to
or refuse your medical treatments for yourself. In Indiana,
these decisions may be made by whomever your doctor
talks to in your immediate family (meaning your spouse,
parent, adult child, brother or sister) or by a person
appointed by a court.
But in Indiana, you can make and write down your own
decisions about your future medical treatment if you wish.
Or you can appoint a person you choose to make these
decisions for you when you are not able to do so. You can
even disqualify someone you don't want to make any health
decisions for you. You can do these things by having what
is called an advance directive. Advance directives are
documents you can complete to protect your rights to
determine your medical treatment and can help your family
and doctor understand your wishes about your health care.
Your advance directive will not take away your right to
continue to decide for yourself what you want. This is true
even under the most serious medical conditions. Your
advance directive will speak for you only when you are
unable to speak for yourself, or when your doctor
determines that you are no longer able to understand
enough to make your own treatment decisions.
What can I do now to express my wishes in case I
later become unable to tell my doctor or my family?
There are three ways you can make your wishes known
now, before you get too sick to tell what treatment you want
or don't want:
1) You can speak directly to your doctor and your family.
2) You can appoint someone to speak or decide for you.
3) You can write some specific medical instructions.
Do I have to fill out more papers?
No. You can always talk with your doctor and ask that your
wishes be written in your medical chart. You can talk with
your family. You don’t have to write down what you want,
but writing it down makes it clear, and sometimes, writing it
down is necessary to make it legal. When you are no
longer able to speak for yourself, Indiana law pays special
attention to what you have written in your advance directive
Do I have to decide about this now?
Which advance directive should I use?
That depends on what you want to do. If you want to put
your wishes in writing, there are three Indiana laws that are
important, the Health Care Consent Act, the Living Will Act,
and the Powers of Attorney Act. These laws may be used
singly or in combination with each other. These laws are
complicated, however, and you may want to talk to a lawyer
if you have specific questions about your legal choices.
What is the Indiana Health Care Consent Act?
The Indiana Health Care Consent Act (IC 16-36-1) lets you
appoint someone to say yes or no to your medical
treatments when you are no longer able. This person is
called your health care representative, and he or she may
consent to, or refuse, medical treatment for you in certain
circumstances that you can spell out. To appoint a health
care representative, you must put it in writing, sign it, and
have it witnessed by another adult.
Because these are serious decisions, your health care
representative must make them in your best interest. In
Indiana, courts have already made it clear that decisions
made for you by your health care representative should be
honored. The decisions can determine which medical
treatment you will or will not receive when you are unable to
express your wishes.
What is the Indiana Living Will Act?
The Indiana Living Will (IC 16-36-4) lets you write one of
two kinds of legal documents for use when you have a
terminal condition and are unable to give medical
instructions. The first, the Living Will Declaration, can be
used if you want to tell your doctor and family that lifeprolonging medical treatments should not be used, so that
you can be allowed to die naturally from your terminal
condition. In a Living Will Declaration, you may choose
whether or not food or water should be artificially provided
as part of your medical treatment or whether someone else
should make that decision for you. The second of these
documents, the Life-Prolonging Procedures Declaration,
can be used if you want all possible life-prolonging medical
treatments used to extend your life.
For either of these documents to be effective, there must be
two adult witnesses and the document must be in writing
and signed by you or someone that you direct to sign in
your presence. Either a Living Will Declaration or a LifeProlonging Procedures Declaration can be cancelled orally,
or in writing, or by canceling or destroying the declaration.
The cancellation is effective, however, only when your
doctor is informed. Both forms are included in this packet.
What is the Indiana Powers of Attorney Act?
The Indiana Powers of Attorney Act is found in the Indiana
Code at IC 30-5. This law spells out how you can give
someone the power to act for you in a lot of situations,
including health care. You do this by giving this person
your power of attorney to do certain things you want this
person to do. This person should be someone that you
trust. He or she does not have to be an attorney, even
though the legal term for this person you appoint is attorney
in fact. The person you name as your attorney in fact is
given the power to act for you in only the ways that you
specify.
Your power of attorney must be in writing and signed in the
presence of a notary public. It must spell out who you want
as your attorney in fact and exactly what powers you want
to give to the person who will be your attorney in fact, and
what powers you don't want to give. Since your attorney in
fact is not required to act for you if he or she doesn't want
to, you may wish to consult with this person before making
the appointment.
If you wish, your power of attorney document may appoint
the person of your choice to consent to or refuse health
care for you. This can be done by making this person your
health care representative under the Health Care Consent
Act, or by referring to the Living Will Act in your power of
attorney document. You can also let this person have
general power over your health care. This would let him or
her sign contracts for you, admit or release you from
hospitals or other places, look at or get copies of your
medical records, and do a number of other things in your
name. You can cancel a power of attorney at any time, but
only by signing a written cancellation and having this
actually delivered to your attorney in fact.
Are there forms to help me write these documents?
Although Indiana law provides limited forms for some of
these purposes listed above, these may not be sufficient to
accomplish everything you might want. Although these
laws do not specifically require an attorney, you may wish
to consult with one before you try to write one of the more
complicated legal documents described above.
Can I change my mind after I write an advance
directive?
Yes. As we mentioned above, you can change your mind
about any of the types of appointments or about the living
will. However, you need to make various people aware that
you've changed your mind - like your doctor, your family or
the person you've appointed - and you might have to
revoke your decision in writing. Remember, however, that
you can always speak directly to your doctor. But be sure
to state your wishes clearly and be sure they are
understood.
What if I make an advance directive in Indiana and I
am hospitalized in a different state, or vice versa?
The law on honoring an advance directive in or from
another State is unclear. Because an advance directive
tells your wishes regarding medical care, however, it may
be honored wherever you are, if it is made known. But if
you spend a great deal of time in more than one State, you
may wish to consider having your advance directive meet
the laws of those States, as much as possible.
What should I do with my advance directive if I
choose to have one?
Make sure that someone, such as your lawyer or a family
member, knows that you have an advance directive and
knows where it is located. You should give a copy of your
power of attorney document to the person you have
appointed to serve as your attorney in fact. You may also
decide to ask your doctor or other health care provider to
make your advance directive a part of your permanent
medical record.
Another idea would be to keep a second copy of the
directive in a safe place where it can be easily found, and
you might keep a small card in your purse or wallet which
states that you have an advance directive and where it is
located or who your attorney in fact is, if you have named
one.
Bloomington Hospital
It is the policy of Bloomington Hospital to allow all adult
patients
with
decision-making
capacity
(including
emancipated minors) to participate in decision-making
concerning their health care and medical treatment.
Bloomington Hospital shall follow advance directives to the
extent permitted and required by Indiana statute.
There may be personal or moral reasons why individuals
choose to prepare or not prepare advance directives.
Bloomington Hospital does not discriminate against an
individual, based on whether or not an advance directive
has been prepared.
Bloomington Hospital is committed to educating its
employees, and the community, on issues concerning
advance directives, and the right of individuals to consent to
or refuse medical treatment.
Final things to remember:
You have the right to control what medical
treatment you will receive.
Even without a lawyer or a form, you can always
tell your doctor and your family what medical
treatments you want or don't want.
No one can discriminate against you for signing an
advance directive.
Using an advance directive is, however, your way
to control your future medical treatment.
Medical Record Number ________________
Bloomington Hospital & Healthcare System
Bloomington, Indiana
For Office Use Only
LIVING WILL DECLARATION
Declaration made this __________ day of _________________________, year of ________.
Being at least eighteen (18) years of age and of sound mind, I, ______________________________________, willfully and voluntarily
make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, and I declare:
If at any time my attending physician certifies in writing that I have an incurable disease, injury or illness; that my death will occur within a
short time; or that the use of life prolonging procedures would serve only to artificially prolong the dying process, I direct that such
procedures be withheld or withdrawn, and that I be permitted to die naturally with only the performance or provision of any medical
procedure or medication necessary to provide me with comfort care or to alleviate pain, and, if I have so indicated below, the provision of
artificially supplied nutrition and hydration. (Indicate your choice by initialing or making your mark before signing this declaration):
______ I wish to receive artificially supplied nutrition and hydration, even if the effort to sustain life is futile or excessively
burdensome to me.
______ I do not wish to receive artificially supplied nutrition and hydration, if the effort to sustain life is futile or excessively
burdensome to me.
______ I intentionally make no decision concerning artificially supplied nutrition and hydration, leaving the decision to my
health care representative appointed under IC 16-36-1 or my attorney in fact with health care powers under IC 30-5.
In the absence of my ability to give directions regarding the use of life prolonging procedures, it is my intention that this declaration
be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the
consequences of the refusal.
I understand the full import of this declaration.
______________________________________________________ ______________________________________________________
Signature
Street Address
______________________________________________________ ______________________________________________________
Print Full Legal Name
City, County & State of Residence
______________________________________________________ ______________________________________________________
Date of Birth
Social Security Number
The declarant has been personally known to me, and I believe (him/her) to be of sound mind. I did not sign the declarant’s signature above
for or at the direction of the declarant. I am not a parent, spouse or child of the declarant. I am not entitled to any part of the declarant’s
estate or directly financially responsible for the declarant’s medical care. I am competent and at least eighteen (18) years of age.
______________________________________________________ ______________________________________________________
Witness Signature
Street Address
______________________________________________________ ______________________________________________________
Witness (Please Print Full Legal Name)
City, County & State of Residence
______________________________________________________
Telephone Number
______________________________________________________ ______________________________________________________
Witness Signature
Street Address
______________________________________________________ ______________________________________________________
Witness (Please Print Full Legal Name)
City, County & State of Residence
______________________________________________________
Telephone Number
11/03
p. 1 of 1
LIVING WILL DECLARATION
*011146*
bc
Medical Record Number ________________
Bloomington Hospital & Healthcare System
Bloomington, Indiana
For Office Use Only
APPOINTMENT OF HEALTH CARE REPRESENTATIVE
I, _________________________________________, voluntarily appoint the following person as my health care representative. My
representative is authorized to act for me in all matters of health care in accordance with IC 16-36-1 and IC 30-5 et. seq., except as
otherwise specified below.
______________________________________________________ ______________________________________________________
Appointed Health Care Representative
Address
______________________________________________________ ______________________________________________________
Telephone Number
City
______________________________________________________ ______________________________________________________
Social Security Number
State & Zip Code
I authorize my health care representative to make decisions in my best interest concerning consent to treatment and the withdrawal or
withholding of health care. If at any time, based on my previously expressed preferences and the diagnosis and prognosis, my health care
representative is satisfied that certain health care is or would be excessively burdensome, then my health care representative may express
my will that such health care would be withheld or withdrawn and may consent on my behalf that any or all health care be discontinued or
not instituted, even if death may result.
My health care representative must try to discuss this decision with me. However, if I am unable to communicate, my health care
representative may make such a decision for me, after consultation with my physician(s) and other relevant health care givers. To the
extent appropriate, my health care representative may also discuss this decision with my family and others, to the extent they are available.
This appointment is to be exercised in good faith and in my best interest subject to the following terms and conditions:
______________________________________________________________________________________________________________
This appointment becomes effective and remains effective if I am incapable of consenting to my health care. I do authorize my health care
representative hereby appointed to delegate decision-making power to another.
Dated this __________ day of _________________________, year of ________.
______________________________________________________ ______________________________________________________
Signature
Street Address
______________________________________________________ ______________________________________________________
Print Full Legal Name
City, County & State of Residence
______________________________________________________ ______________________________________________________
Date of Birth
Social Security Number
I declare that I am an adult at least eighteen (18) years of age and that at the request of the above named individual making the
appointment, I witnessed the signing of this document by the Appointee on the date noted above.
______________________________________________________ ______________________________________________________
Witness Signature
Street Address
______________________________________________________ ______________________________________________________
Witness (Please Print Full Legal Name)
City, County & State of Residence
______________________________________________________
Telephone Number
11/03
p. 1 of 1
APPOINTMENT OF HEALTH CARE REPRESENTATIVE
*011146*
bc